Apparatus for positioning a medical instrument

ABSTRACT

The present device provides an apparatus for securely positioning a medical instrument through an incision within a patient. The apparatus comprises a trocar for extending through the incision in the patient and receiving the medical instrument. The apparatus also comprises a drive assembly for moving the medical instrument within the trocar in a direction that extends substantially parallel to the length of the trocar. The drive assembly can have a housing that is spaced from the trocar or that forms a portion of the trocar. The apparatus also includes a positioning system for rotating the medical instrument about a plurality of spaced points located outside the body and a plurality of perpendicularly extending axes. The positioning system includes an adapter for securing the trocar to the positioning system. A first motor system rotates the adapter and trocar about a first axis that extends substantially perpendicular to the length of the trocar and a second motor system rotates the adapter, the trocar and the drive assembly about a second axis that extends substantially perpendicular to the first axis.

[0001] This application claims the benefit of and incorporates byreference co-pending United States provisional application Serial No.60/376,848 filed May 2, 2002, co-pending U.S. provisional applicationSerial No. 60/427,572 filed Nov. 20, 2002, and co-pending U.S.provisional application Serial No. 60/441,127 filed Jan. 21, 2003.

FIELD OF THE INVENTION

[0002] The present invention relates to an apparatus for positioning asurgical instrument during a surgical procedure, and more particularlyto an apparatus for accurately positioning and repositioning aninstrument, such as an endoscope, during a surgical procedure, such aslaparoscopic surgery.

BACKGROUND OF THE INVENTION

[0003] Accurate and precise manipulation of surgical instruments at ornear a surgical site is required during any surgical procedure. However,this is especially true for minimally invasive endoscopic surgicalprocedures, such as laparoscopic surgery, in which the doctor has alimited amount of room to maneuver the instrument. While the followingdiscussion relates to laparoscopies, it is equally applicable to any forendoscopic procedure.

[0004] As is well-known, laparoscopic surgery (laparoscopy) is aprocedure in which surgical instruments and an endoscope, referred tonormally as a laparoscope, are inserted into the abdominal cavity of apatient through a hollow tubular device positioned within a smallincision in the patient. These tubular devices are commonly referred toas trocars or cannulas and remain in the incision throughout theprocedure. The laparoscope comprises an illuminated tube and an opticalsystem that is inserted through the tubular device in the abdominal wallfor examining the abdominal cavity. The optical system includes an imagereceiving lens that can be connected to a remotely positioned monitor.

[0005] Endoscopes are presently hand held or positioned with complicatedand expensive devices. They are constantly being repositioned to obtainthe best view. When hand supported throughout the surgical procedure,the laparoscope must be constantly manually manipulated by the surgeon,assistant surgeon, and/or a scrub nurse in order to direct it at thetarget of the surgery. This process ties up one hand of the surgeon orassistant surgeon, if either holds the scope. The scrub nurses haveother tasks to perform, and holding the scope interferes with performingthese tasks. It is also difficult for the surgeon to direct others toposition the scope for the best view. When the surgeon does not hold thescope, it is often misdirected. This can result in injury to the patientand delays in the conclusion of the surgery.

[0006] Mechanical support of a laparoscope has been providedconventionally using a robotic arm. However, these arms face many of thesame problems encountered when the laparoscope is held by hand. Forexample, the movements of the laparoscope can be in the wrong directionand/or to an improper depth within the body. Additionally, these roboticsystems can take up too much space in the operating room and requiresomeone to constantly monitor and operate it. This unnecessarily ties upone of the members of the operating team and can contribute to crowdingof the operation site. Additionally, many of the conventional systemsallow the laparoscopes to bend and twist within the body, therebystretching the incision.

[0007] Moreover, some conventional positioning systems typically attachto the instrument or laparoscope at a point above the trocar, which isapproximately 4 to 8 inches above the abdomen wall. This creates ageometrical challenge to maintain an X and Y-axis pivot point at theincision of the abdominal wall and a stable image. Typically the abovementioned complicated and expensive mechanical linkages that extend overthe patient are used to accomplish this positioning without any shakingof the image.

SUMMARY OF THE INVENTION

[0008] The present device provides an apparatus for securely positioningan endoscope within an incision within a patient. The apparatuscomprises a trocar for extending through the incision in the patient.The apparatus also comprises a drive assembly for moving the endoscopewithin the trocar in a direction that extends substantially parallel tothe length of the trocar. The apparatus further includes a first motorsystem for rotating the adapter and medical instrument about a firstaxis that extends substantially perpendicular to the length of themedical instrument and a second motor system for rotating the adapter,the medical instrument and the drive assembly about a second axis thatextends substantially perpendicular to the length of the trocar and thefirst axis.

[0009] In an embodiment, the endoscope is placed through a housing ofthe drive assembly that contains an electric motor, which can advancethe length of the endoscope in and out (the Z-axis motor) of the body.This motion also performs a zoom in/zoom out focusing function. TheZ-axis motor is attached to an electrically motorized drive roller,which can move the endoscope along a Z axis. An X-axis pivot isrotatably connected to a substantially horizontal tube, which ispositioned on the surface of the patient. Bevel gears and an X-axiselectric motor are mounted inside the horizontal tube. The horizontaltube extends across the exterior of the patient and is perpendicularlyconnected to a motorized cam. The motorized cam moves the endoscopethrough the Y-axis by rotating the horizontal tube. A remote controlallows a user to control the positioning of the endoscope by activelyand accurately moving the endoscope through its X, Y and Z-axes. Thisapparatus provides a broad range of motion of the endoscope and alsohelps to stabilize the image when compared to hand held endoscopes.

[0010] An aspect of the present invention includes a system forpositioning a medical instrument relative to a patient. This systemcomprises a drive assembly for moving the medical instrument relative tothe patient in a direction that extends substantially parallel to afirst axis. The first axis is substantially parallel to the length ofthe medical instrument when the medical instrument is positioned withinthe drive assembly. The system also comprises a positioning systemsupported for movement relative to the patient and operatively connectedto the drive assembly for rotating the medical instrument. Thepositioning system according to this aspect comprises (a) a first motorsystem located at a first section of the positioning system for rotatingthe drive assembly and the medical instrument about a second axis thatextends substantially perpendicular to the first axis and a first pointlocated outside the body of the patient when a portion of the medicalinstrument is positioned within the body of the patient; and (b) asecond motor system located at a second section of the positioningsystem for rotating the drive assembly about a third axis that extendssubstantially perpendicular to the second axis and a second pointlocated outside the body of the patient when a portion of the medicalinstrument is positioned within the body of the patient.

[0011] Another aspect of the present invention comprises an apparatusfor positioning a medical instrument relative to a patient that includesa drive assembly for moving the medical instrument relative to thepatient. The drive assembly comprises a motor for moving the medicalinstrument in a direction that extends along a first axis andsubstantially parallel to the length of the medical instrument. Theapparatus also includes a medical instrument positioning systemcomprising a plurality of elongated members operatively connected to andsupporting the drive assembly; a first motor system including a motorfor rotating the medical instrument in opposite directions about a pointpositioned outside the body of the patient when a portion of the medicalinstrument is positioned within the body of the patient and a secondaxis that extends substantially perpendicular to the first axis; and asecond motor system including a motor for rotating the medicalinstrument and the plurality of positioning system members about asecond axis that extends substantially perpendicular to the length ofthe first axis.

[0012] A further aspect of the present invention includes apparatus forpositioning a medical instrument relative to a patient comprising afirst elongated medical instrument moveable relative to the body of thepatient, a drive assembly for engaging the first elongated medicalinstrument and moving the first elongated medical instrument toward andaway from the body of the patient; and a positioning system operativelyconnected to the drive assembly and the first elongated medicalinstrument for moving the first elongated medical instrument about aplurality of axes and a plurality of spaced points located outside thebody of the patient.

[0013] An additional aspect of the present invention includes anapparatus for positioning a medical instrument relative to a patientcomprising a vertical support member and a first motor system supportedby the vertical support member. The first motor system includes a motorand a drive system. The apparatus also includes a first link having afirst end pivotally secured to the vertical support member, wherein thedrive assembly is operatively coupled to the first end of the first linkfor driving the first link about a pivot point. The apparatus furtherincludes an arm having a first portion secured at a fixed angle to aportion of the first link. The arm is secured to the first link at aportion spaced from the first end of the first link. The arm includes asecond motor system. The apparatus also includes an adapter having afirst end secured at a fixed angle to a second portion of the arm. Theadapter operatively connected to the second motor system for rotatingthe adapter relative to the arm. The adapter is capable of supportingthe medical instrument.

[0014] The present invention overcomes disadvantages of the prior artdevices. Generally, the present invention provides a medical instrumentpositioning apparatus that provides for adjustment of the medicalinstrument, such as a laparoscope, once it is positioned through anincision, without stressing the tissue surrounding the incision beyondits acceptable levels. The apparatus also uses the natural elasticity ofthe abdominal wall tissue by distending the abdominal wall tissue lessthan or equal to the tissue distention found during typical laparoscopicprocedures that do not use support systems. The present inventionmaintains the orientation of the laparoscope so that it will not twistor tip over while extending through the incision. Additionally, thearrangement of the apparatus is less cumbersome than the linkages, whichusually contain parallelograms, typically found in other systems and itcan be operated using a single hand and/or a foot.

[0015] These and other features and advantages of the present inventionwill be apparent from the preferred embodiment described in thefollowing detailed description and illustrated in the accompanyingdrawings.

BRIEF DESCRIPTION OF THE DRAWINGS

[0016]FIG. 1A is an isometric view of a first embodiment of an apparatusfor positioning a medical instrument according to the present invention;

[0017]FIG. 1B is an isometric view of a second embodiment of anapparatus for positioning a medical instrument according to the presentinvention;

[0018]FIG. 2 is a cross section of a C-shaped arm taken along the line2-2 of FIGS. 1A and 1B;

[0019]FIG. 3 is an end view of the C-shaped arm taken proximate a trocaradapter rotated ninety degrees about the X and Y axes relative to FIG.2;

[0020]FIG. 4 is a side isometric view of the apparatus illustrated inFIGS. 1A and 1B;

[0021]FIG. 5 illustrates a portion of the trocar adapter and a portionof a middle section of the C-shaped arm;

[0022]FIG. 6 illustrates the apparatus of FIGS. 1A and 1B before anendoscope is introduced into the trocar adapter;

[0023]FIG. 7 is an isometric view of a motor housing according to thepresent invention;

[0024]FIG. 8 is an isometric view of the motor housing of FIG. 7 with acover removed;

[0025]FIG. 8A is an isometric view of a motor housing include a pair ofmotors and two pairs of rollers that provide longitudinal and rotationalmotion to a medical instrument;

[0026]FIG. 9 is a side view of the apparatus illustrated in FIGS. 1-8;

[0027]FIG. 10 illustrates a foot-activated controller that can be usedwith the apparatus shown in FIGS. 1A and 1B;

[0028] FIGS. 11A-11E illustrate different embodiments of a trocaradapter according to the present invention;

[0029]FIG. 12 illustrates a securing system for attaching a stanchion toa rail of an operating room table and permitting controlleddegree-by-degree movement of the stanchion relative to the operatingtable and a patient;

[0030]FIGS. 12A and 12B illustrate a motor for rotating a positioningsystem located within a vertical stanchion;

[0031]FIG. 13 illustrates the securing system of FIG. 12 secured to arail;

[0032]FIG. 14 is an enlarged view of a portion of FIG. 13;

[0033]FIG. 15 is a perspective view of the securing system of FIG. 12;

[0034]FIG. 16 illustrates a support plate and brackets for attaching thesecuring system to the rail;

[0035]FIG. 17A-FIG. 17F illustrate different view of the securing systemof FIG. 12;

[0036]FIGS. 18 and 19 illustrate an alternative embodiment of a trocarsupport member according to the present invention;

[0037]FIG. 20 is a schematic view of a support member for a medicalinstrument that is free of an attachment to a trocar according toanother embodiment of the present invention;

[0038]FIG. 21 is a schematic top view of the support member of FIG. 20;

[0039]FIGS. 22A and 22B are schematic views of the support member ofFIG. 20 with drive rollers in alternative alignments, perpendicular tothat shown in FIG. 20;

[0040]FIG. 23 is a schematic view of the support member of FIG. 20 withan additional roller on one side for supporting the alignment of themedical instrument;

[0041]FIG. 24 is a schematic view of a trocar connected to a C-shapedarm according to another embodiment of the present invention, the trocarincludes a motor housing with motors and rollers for advancing andretracting a medical instrument;

[0042]FIGS. 25 and 26 are side schematic views of the trocar of FIG. 24;

[0043]FIG. 27 is a fragmentary view of an embodiment of the trocar witha motor housing having driven rollers carrying centrally positionedmotors;

[0044]FIGS. 28 and 29 illustrate the trocar with motor housing of FIG.27 including an inserted instrument;

[0045]FIG. 30 is a schematic view of the trocar with motor housing ofFIG. 27;

[0046]FIG. 31 is an isometric view of a trocar with a trocar motorhousing according to an alternative embodiment of the present invention;

[0047]FIG. 32 is a schematic view of the trocar motor housing of FIG. 31with the internal parts of the trocar motor housing shown in brokenlines;

[0048]FIG. 33 is a rear schematic view of the trocar motor housing ofFIG. 31;

[0049]FIG. 34 is a top plan view of a trocar motor housing according toan alternative embodiment of the present invention;

[0050]FIG. 35 is a side view of the trocar motor housing of FIG. 34 withan endoscopic instrument extending there through;

[0051]FIG. 36 is a schematic cross-sectional view of the trocar motorhousing of FIG. 34 with a driven roller and pinch roller in position fordriving an endoscopic instrument;

[0052]FIG. 37 is a schematic cross-sectional view of the trocar motorhousing of FIG. 34 with the pinch roller of the motor housing beingpivoted away the driven roller;

[0053] FIGS. 38A-38E illustrate an alternative embodiment of anadjustable trocar support member according to the present invention;

[0054]FIGS. 38F and 38G are cross sections of the drive assembly with apivotable lever in a released position and a depressed positionillustrated in FIG. 38A;

[0055]FIG. 38H is a bottom view of the drive assembly illustrated inFIG. 38A; and

[0056]FIGS. 38I and 38J are side views of the drive assembly illustratedin FIG. 38A.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT

[0057]FIGS. 1A and 1B show an apparatus 10 for supporting andpositioning a conventional medical instrument 12 relative to anoperating table that has an equipment mounting member or a horizontallyextending edge to which the apparatus 10 can be secured. Embodiments ofsuch an apparatus 10 are discussed in U.S. Provisional PatentApplication No. 60/376,848, which is hereby incorporated by reference.Known medical instruments 12 include graspers, forceps, cauterizingdevices, endoscopes and all other instruments used in endoscopicprocedures. In other embodiments, the medical instrument 12 can includea drill, a trocar or other piercing device. For ease of explanation andclarity, the following description of the present invention will discussthe apparatus 10 and how it positions and supports an endoscope,specifically a laparoscope. However, the following discussion is notlimited to laparoscopes. Instead, it is equally applicable to otherendoscopes and other medical equipment that require stable support andaccurate positioning during medical procedures.

[0058] The laparoscope 12 illustrated in FIGS. 1A, 1B and 9 can be anyknown conventional laparoscope that includes an eyepiece 18 mounted onthe end of a viewing tube 19. The viewing tube 19 also includes a videocamera 17 that is connected to a video monitor (not shown) that islocated proximate the surgical site. The laparoscope 12 also includes alight source (not shown) that is connected to a light cable 13 thattransmits light from the light source to an end of the light cable 13positioned in the abdominal cavity. The light is directed out of the endof the tube 19 for illuminating the body cavity. The body cavity is thenviewed by a video camera 17 connected to the monitor by a connectingcable 14 (FIG. 4).

[0059] Apparatus 10 includes a stanchion 90 that has a base 36, asecuring system including a base clamp 38 and a jaw 39 for securing theapparatus to a support such as a support rail or edge of an operatingtable as shown in FIG. 1A. Manual turning of a lever 42 screws a clampshaft for moving the jaw 39 relative to a base member that is positionedon an opposite side of the support from the jaw 39. However, any knownmanner of securing an endoscope support system relative to an operatingtable may be used. One such way is disclosed in U.S. Pat. No. 5,571,072which is incorporated herein by reference.

[0060] As shown in FIGS. 1A, 1B and 2, the apparatus 10 includes a “C”shaped arm 40 that operates as a positioning system and that rotatesrelative to the patient. The C-shaped arm 40 also rotates relative tothe vertical stanchion 90, as well as, moving linearly relative to thestanchion 90. An elongated member 91 connects the C-shaped arm 40 to astanchion housing 92 supported on the stanchion 90 as shown in FIG. 1A.The housing 92 receives the elongated member 91 and the verticalstanchion 90. The housing 92 is also moveable relative to both thestanchion 90 and the elongated member 91. As a result, the housing 92and the C-shaped arm 40 can be positioned at any point along the lengthof the stanchion 90. This stanchion length can be in either a horizontaldirection (X axis) or a vertical direction (Y axis). Additionally, theC-shaped arm 40 can be positioned a distance away from the housing 92.This distance can be adjusted by moving elongated member 91 in or out ofthe housing 92 in a direction perpendicular to the length of thestanchion 90. In an alternative embodiment illustrated in FIG. 1B, theC-shaped arm 40 is secured directly to the stanchion housing 92. Weldsor fasteners, such as screws or bolts, can be used to secure theC-shaped arm 40 directly to the stanchion.

[0061] As discussed below with respect to drive system housing 61, thehousing 92 can include two or more powered rubber pinch rollers thatfrictionally engage the stanchion 90 and move the housing 92 along thelength of the stanchion 90. Similarly, two or more powered rubber pinchrollers can also be used to move the elongated member 91 into and out ofthe housing 92. As with the stanchion 90, the rollers apply compressivepressure to the elongated member 91 and move the elongated member 91 inthe direction that they rotate. A driven rubber pinch roller and arubber idler roller could be used in place of the two or more drivenrubber rollers.

[0062] In another alternative embodiment, the housing 92 can be movedmanually relative to stanchion 90 and member 91 via known linear ballbearings, bushings or other bearing surfaces through which the stanchion90 and elongated member 91 extend. In this embodiment, the housing 92includes a known friction lock that can be manually applied to thestanchion 90 when the housing is at the proper height along stanchion 90such as friction member 123 discussed, below. Manually applied frictionlocks, like friction member 123, can also be used to secure the housing92 along the elongated member 91.

[0063] In any of the discussed embodiments, the elongated member 91 caninclude a hollow tube with an internal lumen carrying an elongated driveshaft 136 (FIG. 2). Alternatively, the elongated member 91 can rotatefreely within the pinch rollers or linear bearings about the axis alongwhich the elongated member 91 moves relative to the housing 92.

[0064] FIGS. 12-17 illustrate an additional embodiment of a securingsystem 200 that can be used with any of the embodiments of the medicalinstrument support and positioning apparatus 10 discussed herein tosecurely position such an apparatus on a rail 205 of a surgical tableduring a medical procedure. In these embodiments, as well as othersdisclosed herein, the C-shaped arm 40 can be rotated about the Y-axis bythe operation of a motor 910 within the stanchion 90. As illustrated inFIGS. 12A and 12B, the stanchion 90 can include the motor 910 and apower source 950. As with any of the embodiments discussed herein, thepower source 950 can include a DC power source such as batteries or anAC power source. The motor 910 includes a drive shaft 923 that drives agear system 920 with an output shaft(s) connected to the links 120. Aconventional worm drive gear system including a worm gear and a drivengear, or a beveled gear system including a driven gear and a followergear can be used to transfer the motion of the drive shaft to the links120. This motion will cause the links 120 and the remainder of theC-shaped arm 40 to pivot (rotate) about a pivot axis 945 that extendssubstantially parallel to, and coextensive with, the Y-axis. A pin 948can be positioned within the links 120 at a fist end for rotatablycoupling the links 120 to the stanchion 90. A clamp 980 can be includedfor releasably receiving the middle section 44 within the links 120.

[0065] The securing system 200 also permits rotation of the apparatus 10about the rail 205. The securing system 200 includes a rail mountingplate 220 and a pair of brackets 222 that receive the rail 205 andpositioning of the C-shaped arm 40. Each bracket 222 includes an opening224 for receiving a portion of the rail 205. In one embodiment, theopening 224 is slid over the rail 205 so that the only motion that thebrackets can achieve relative to the rail 205 is a sliding motion alongthe length of the rail 205. The brackets 222 can be closed blocks orinclude openings along their rear face (facing the operating table). Asshown in FIGS. 16 and 17(e), the plate 205 is frictionally securedagainst sliding (longitudinal) movement relative to the rail 205 by apair of stopping members 208 that are advanced through the plate 220 andinto frictional engagement with the rail 205. When the grasping members209 of the stopping members 208, such as knobs, are rotated, thestopping members 208 are rotated into engagement with the rail 205 ordisengagement from the rail. As can be understood, this will depend onthe direction of rotation. Other known ways of advancing the stoppingmembers 208 into engagement with the rail 205 can also be used. Theseother known ways include the use of controlled motors.

[0066] The securing system 200 also includes a clamping bracket 210 forreceiving the vertical stanchion 90. As illustrated in FIG. 12, theclamping bracket 210 includes first and second sections 211 that arelocked together to securely hold the vertical stanchion 90 and preventmovement of the stanchion 90 relative to the bracket 210. The bracket210 is mounted to a rotatable disk 215 that is secured to an associatedpositioning gear 218 having a plurality of teeth. The positioning gear218 is rotatably secured within a bearing positioned within plate 220(see FIG. 16). As shown in FIGS. 14 and 15, a cooperating locking gear228 is located on the plate 220 for engaging with the teeth of thepositioning gear 218. Both gears 218, 228 can be driven by hand or by anassociated motor. The locking gear 228 is secured to a handle 229 thatwhen turned to a locking position holds and prevents rotational motionof both the locking gear 228 and the positioning gear 218 with whichlocking gear 228 is engaged. As a result, the stanchion 90 is preventedfrom rotating relative to the rail 205. In an alternative embodiment,the rotation and braking of the desired, predetermined rotation of thestanchion 90 can be achieved by the controlled operation and braking ofa conventional drive motor.

[0067] The tubular C-shaped arm 40 of any of the above-discussedembodiments has a first end section 42, a second end section 46 and amiddle section 44 that extends between the two end sections 42, 46. Asshown in FIGS. 1A and 1B, the first end section 42 is distal thestanchion 90 relative to the second end section 46. The first endsection 42 and the middle section 44 are tubular with open internallumens extending along their length. The cross sections of thesesections 42, 44 can be round, oval or rectangular. Other known shapescan also be used. The middle section 44 can be positioned along aportion of the patient's body during the medical procedure. In oneembodiment, the middle section 44 should be positioned so that the pivotpoint 49 of the C-shaped arm 40 is at the skin surface of the patient.As illustrated in FIGS. 1A, 1B and 2, the first end section 42 and thesecond end section 46 extend substantially perpendicular to the lengthof the middle section 44. The second end section 46 includes a fixedlink segment 120 or multiple fixed link segments 120 (FIG. 12) having asubstantially rectangular shape with rounded ends.

[0068] During the medical procedure, a small incision is made in theabdomen of the patient and a trocar 20 (also referred to as a cannula)is introduced into the abdominal cavity through the incision in order toestablish a pathway along which medical instruments such as thelaparoscope 12 can enter the body. After the trocar 20 is properlypositioned within the incision, the C-shaped arm 40 can be secured tothe trocar 20 as discussed below.

[0069] As shown in FIGS. 1A, 1B and 9, the first end section 42 includesan endoscope positioning system 50 that adjusts the distance that thelaparoscope 12 extends within the patient and a first angular componentof the position of the laparoscope 12. The endoscope positioning system50 is secured to the trocar 20 by a connector 31. As a result, relativemovement between the endoscope positioning system 50 and the trocar 20is prevented. As shown in FIGS. 4 and 9, the connector 31 extendsbetween a Z-axis medical instrument drive assembly 60 and the trocar 20.As discussed herein, the medical instrument can include an endoscope.The connector 31 is secured to the laparoscopic drive assembly 60 in anyconventional manner, such as by using threaded fasteners or brackets,that prevents their relative movement. The connector 31 is also securedto the trocar 20 in any known manner. In one embodiment, a closeablecollar is secured around the end of the trocar 20 distal the patient. Inan alternative embodiment, the end of the trocar 20 distal the patientis friction or force fitted within an opening in the end of theconnector 31 opposite the drive assembly 60. Other known ways ofcoupling a tube to a housing can also be used.

[0070] As shown in FIGS. 7 and 8, the endoscope positioning system 50includes the drive assembly 60 having a housing 61 with an endoscopereceiving opening 59. The housing 61 is attached to the trocar 20positioned within the abdominal cavity by the connector 31 as discussedabove. The laparoscopic drive system housing 61 contains a motorassembly 62 that includes a driven rubber pinch roller 63 and a springbiased rubber idler roller 64. The rubber can include a silicon rubberhaving a durometer of between about forty and sixty. In one preferredembodiment, the durometer is about 50. Other known compressiblematerials having a high coefficient of friction and a durometer in therange of between about forty to sixty can be used in place of rubber forthe rollers 63, 64. The rollers 63, 64 are not limited to theabove-discussed durometers.

[0071] In one embodiment, the pinch roller 63 includes a V-shaped groove69 for receiving the laparoscope 12 and providing pressure on it frommultiple sides. A motor 65 drives the pinch roller 63 via a rotatabledrive shaft 66. Batteries 67 or another electrical source powers themotor 65. The batteries 67 or other power source could also be locatedoutside of housing 61. The idler roller 64 is biased into contact withthe shaft of the laparoscope 12 by a set of coil springs 68 positionedbetween the idler roller 64 and a stationary object such as the innerwall of the housing 61. The biasing force applied by the springs 68forces the idler roller 64 into contact with the laparoscope 12 andcreates enough friction that the laparoscope 12 moves in the directionthat the driven roller 63 rotates. The springs 68 and the V-groove 69permit the rollers 63, 64 to accept any size laparoscopic shaft thatwill fit within the housing 61. It is contemplated that one or moresprings could be used. Also, other types of springs can be used.

[0072] As the driven pinch roller 63 is operated, the laparoscope 12 ismoved along a “Z” axis for advancing the laparoscope 12 into orwithdrawing the scope from the abdomen via the trocar 20. As shown inthe FIGS. 1A and 1B by the arrow labeled “Z”, the Z axis extends in thedirection that is perpendicular to the midline of the body and out ofthe paper of FIGS. 1A, 1B and 2. By advancing and withdrawing thelaparoscope 12 using the drive assembly 60, the field of view of thelaparoscope 12 and the image on the video monitor will change. Forexample, as the laparoscope 12 is advanced into the abdomen by therotation of the driven pinch roller 63 in the direction of the patient,the practitioner can zoom in on the desired area within the body for aclose up video image. Conversely, the retraction of the laparoscope 12caused by the driven pinch roller 63 rotating away from the patientwidens the field of view of the image on the monitor and permits thepractitioner to view more of the body cavity.

[0073] As illustrated in FIG. 8A, the housing 61 could also include asecond motor assembly 62′ and a second set of rollers 63′, 64′ that aresimilar to rollers 63, 64 for rotating the laparoscope 12 about itslongitudinal axis. These rollers 63′, 64′ are oriented perpendicular tothe rollers 63, 64 so that their axes of rotation extend parallel to thelongitudinal axis of the laparoscope 12 when the laparoscope 12 ispositioned between the rollers 63, 64. As a result, when the motor 65′rotates the driven roller 63′, a rotatably secured plate 66′ on whichthe drive assembly 60 is secured rotates about the longitudinal axis ofthe trocar (not shown). In response to the rotation of the plate 66′,the laparoscope 12 secured between the grooves of the driven andspring-biased pinch rollers 63, 64 will rotate about its longitudinalaxis.

[0074] In addition to the controlled movement of the laparoscope 12along the Z axis, controlled rotational movement about an X axis canalso be achieved. As shown in FIGS. 1A, 1B and 2, the first end section42 includes a trocar adapter 70 and an adapter shaft 72 that connectsthe trocar adapter 70 to the middle section 44 of the C-shaped arm 40.As used herein, the term “adapter” includes the member(s) or system(s)that connects a trocar and/or drive assembly to the first end section 42and supports the trocar and/or drive assembly relative to the first endsection 42 such that the medical instrument 12 will move with themovement of the C-shaped arm 40. The adapter shaft 72 has a diameter ofabout 0.187 inch and a length of about 1.5 inch. The trocar adapter 70and adapter shaft 72 cause the laparoscope 12, the camera 17 and thetrocar 20 to rotate about the X axis so that the field of view or thelocation of the procedure can be altered. The direction of thisrotational motion is shown in FIGS. 1A and 1B by the illustrated arrows.As seen in the figures, the trocar 20 is received within an opening 74in the adapter 70. The inner surface 75 of the opening 74 acts as abearing when the trocar 20 is being advanced into the adapter 70. Theopening 74 can be sized to create a friction fit with the trocar 20 sothat the trocar 20 will not unintentionally move relative to the adapter70. As the adapter shaft 72 is rotated, the inner surface 75 transfersthe rotational motion of the adapter 70 to the indwelling trocar 20, thelaparoscope 12 and the camera 17. In one embodiment, the trocar adapter70 is formed of a disposable plastic material. However, the trocaradapter 70 could also be formed of reusable, sterilizable materialsincluding sterilizable plastics and sterilizable metals such asstainless steel.

[0075] As illustrated in FIGS. 11A-11D, the trocar adapter 70 caninclude a quick release clamping mechanism 140 that allows the trocar 20to be quickly and removably secured within the adapter 70. In theembodiments illustrated in FIGS. 11A-11D, the trocar adapter 70 includesat least two sections 71′ and 72′ that are moveable relative to eachother in order to create a larger opening for the introduction of thetrocar 20 into the adapter 70. After the trocar 20 has been introducedinto the adapter 70, the sections 71′ and 72′ are closed around thetrocar 20 and secured to each other in order to hold the trocar 20within the adapter 70. A first embodiment of the clamping mechanism 140,shown in FIG. 11A, includes a pivot member 141, such as a hinge, on oneside of the adapter 70 and a fastener 142 for holding sections 71′ and72′ together on the opposite side of the adapter 70. The fastener 142can include a threaded member that engages threads located within thesections 71′ and 72′ or in a nut positioned in either section 71′ or72′. Alternatively, the fastener 142 could include a push-in fastenerthat frictionally and/or mechanically engages with sections 71′ and 72′to prevent their relative movement and to prevent the longitudinalmovement of the trocar 20 relative to the trocar adapter 70.

[0076] As shown in FIG. 11B, the clamping mechanism 140 can include apivot hinge 141 connected to sections 71′ and 72′ for their relativemovement. The clamping mechanism also includes a flexible catch hook 144that extends from section 71′ and engages a recess 145 formed in section72′. When the catch hook 144 is not engaged with the recess 145, thetrocar adapter 70 can be opened for receiving the trocar 20. After thetrocar 20 is received between the sections 71′ and 72′, the catch hook144 is engaged with the recess 145 and the trocar adapter 70 is securelyclosed about the trocar 20 in order to prevent longitudinal movement ofthe trocar relative to the trocar adapter 70. As clearly understood, thecatch hook 144 can extend from either section 71′ or 72′ and the recesscan be formed in the other of the sections 71′ or 72′.

[0077]FIG. 11C illustrates another embodiment of the clamping mechanism140 that includes a first section 71′ of the trocar adapter 70 securedto the adapter shaft 72 and a removable cap section 72′ that can beseparated from the first section 71′ in order to introduce the trocar 20into the trocar adapter 70. After the trocar 20 has been introduced, thecap section 72′ can be secured to the first section 71′ by threaded orpush-in fasteners 142, such as those discussed above with respect toFIG. 11A.

[0078]FIG. 11D illustrates an embodiment in which the clamping mechanism140 includes two pivotable sections 71′ or 72′ that are spring biasedtoward each other by a spring 146. Any known type of spring can be usedfor spring 146, for example a helical coil spring is shown in FIG. 11D.As can be understood, the spring 146 biases the sections 71′ or 72′toward each other in order to keep the trocar adapter 70 closed aboutthe trocar 20. However, when the trocar 20 is to be removed or inserted,handles 147 are grasped and squeezed toward each other and opposite tothe bias of spring 146. This action opens the trocar adapter 70. Whenthe trocar 20 has been inserted/removed from the trocar adapter 70, thehandles 147 are released and the spring 146 forces the sections 71′ or72′ toward each other in order to securely hold the trocar 20 within thetrocar adapter 70.

[0079]FIG. 11E illustrates an embodiment in which any one of theabove-discussed embodiments of the trocar adapter 70 includes a couplingsystem 79′ with a shaft 73′ that is removably and rotationally securedto an adapter shaft 172 for easy removal of the trocar adapter 70. Theadapter shaft 172 is substantially the same as shaft 72 except for thatdiscussed below. The shaft 73′ includes a recess 74′ that receives amulti-sided member 75′ extending from an end of the adapter shaft 172 asillustrated in FIG. 11F. The member 75′ has a plurality of flat,elongated surfaces 76′ that engage corresponding surfaces of the recess74′ in order to transfer rotational motion of the shaft 172 to the shaft73′. The connection between the shaft 73′ and the shaft 172 illustratedin FIG. 11E is enclosed by a connector including a movable outer sleeve75′ that has an internal groove 77′ for receiving ball bearings 78′. Therelease of the trocar adapter 70 from the shaft 172 can be accomplishedby sliding or otherwise moving the outer sleeve 75′ as described in U.S.Pat. No. 5,470,180 to Jore that is hereby incorporated by reference.However, other known quick release couplers, including those discussedabove, can also be used. Additionally, the trocar adapter 70 can beeasily and quickly removed if a larger or smaller sized trocar adapter70 is needed during the medical procedure.

[0080] In any of the discussed embodiments, the adaptor shaft, includingshafts 72, 172 (herein after all identified as “72” for clarity and easeof understanding) is received and supported by bearings 76 (or bushings)in a first end 43 of the middle section 44 or a removable, disposablesleeve 198 that covers an end of the middle section 44. These bearings76 permit the rotation of the adapter shaft 72 and the laparoscope 12relative to the middle section 44 in response to the operation of amotor system including a first gear 84, a cooperating second gear 85 anda motor assembly 88. The adapter shaft 72 includes the first gear 84 ofa matched set of beveled gears 83. The second gear 85 of the matched set83 is securely attached to a drive shaft 87 of an X axis motor assembly88 contained within the middle tubular section 44 of the C-shaped arm40. As shown in FIG. 2, the gears 84 and 85 mesh with each other so thatthe first gear 84 and the trocar adapter 70 will rotate when therotation of the drive shaft 87 causes the second gear 85 to rotate. Byrunning the X axis motor assembly 88 in forward or reverse, the adaptorshaft 72, the adaptor 70, the trocar 20, the laparoscope 12 and theZ-axis laparoscopic drive assembly 60 are rotated about the radial planeof the X axis. This allows the surgeon or attendant to control theposition of the laparoscope 12 and the provided image around the X axisin a 180-degree radius as measured from the incision point in theabdomen. The laparoscope 12 will also pivot about the point where it issecured to the adapter 70. As illustrated in FIG. 2, the laparoscope 12will pivot about the point 490 that is located outside the body of thepatient so that the skin of the patient will not be injured during therotation of the laparoscope 12.

[0081] The laparoscope 12 can also be rotated about a “Y” axis so thatadditional manipulation of the laparoscope's 12 field of view can beachieved. The Y axis rotation of the laparoscope 12 is accomplished bythe rotation of the entire C-shaped arm 40 about the Y axis. The Y axisextends perpendicular to the X axis about which the trocar adapter 70rotates and the direction that the laparoscope moves in response to therotation of the rollers 63, 64.

[0082] As shown in FIGS. 1A, 1B, 2 and 6, the second end section 46 ofthe C-shaped arm 40 includes the fixed link segment 120 that isconnected at a first end 122 to the middle section 44 and at a secondend 124 to a gearbox assembly 130. The first end 122 of the fixed link120 includes an internal linear bearing 196 that receives an end of themiddle section 44 of the C-shaped arm 40 so that the distance the trocaradapter 70 is spaced from the stanchion 90 can be adjusted. In oneembodiment, the linear bearing is a ball bearing. Also, a clamp or otherknown holding/friction member 123 can be positioned over the end ofmiddle section 44 and the fixed link 120 to prevent their relativemovement. For example, as illustrated in FIG. 6, the member 123 includesa piece of friction material 192, such as DELRIN plastic or any otherknown friction causing material, that is coextensive with at least aportion of the middle section 44 that extends through the fixed link120. The friction material 192 extends between the linear bearing andshaft of middle section 44. A thumbscrew or knob 193 is connected to ashaft 195 that is threaded into the fixed link 120. When the knob 193 isrotated so that the shaft 195 advances into the fixed link 120, thefriction member 123 engages middle section 44 and prevents it frommoving relative to the fixed link 120. The middle section 44 can bemoved relative to the fixed link 120 by hand, by a motor or by using amotor combined with manual manipulation. The motor can be used forstepwise distance adjustments and the manual manipulation can be usedfor finite distance adjustments. Alternatively, the end of middlesection 44 is secured to the inner surface of an opening 125 in thefixed link 120 in a known manner.

[0083] The second end 124 of the fixed link 120 includes fixed shaft 126that is securely positioned within an opening 127 so that it will notrotate relative to the fixed link 120. Instead, the fixed shaft 126transfers any imparted rotary motion to the fixed link 120 and theC-shaped arm 40. The fixed shaft 126 is spaced from a center point ofthe fixed link's length so that eccentric rotational movement of thefixed link 120 can occur. As shown in FIGS. 2 and 6, the fixed shaft 126is also secured to a first gear 132 located within a gear housing 130. AV-axis motor system includes the first gear 132, a Y-axis drive gear134, a drive shaft 136 and a motor 135. As illustrated, the first gear132 engages the Y-axis drive gear 134 secured to an end of the driveshaft 136 extending from the Y-axis motor 135. The rotation of the driveshaft 136 during the operation of the Y-axis motor 135 causes the meshedfirst gear 132 to rotate. This in turn causes the fixed link 120 and theother sections 42, 44 of the C-shaped arm 40 to rotate about the Y axis.The Y-axis motor 135 can be located in the housing 92 and the driveshaft 136 can extend through the drive member 91 or form part of thedrive member 91. In this embodiment, the gear 134 is positioned withinthe gearbox housing 130 with gear 132. Alternatively, as shown in FIGS.1A, 1B and 6, the Y-axis motor 135 is secured directly to the gearboxhousing 130 that contains the gears 132 and 134. In the embodimentillustrated in FIGS. 1B and 6, the stanchion 90 is secured directly togearbox housing 130. Operation of the Y-axis motor 135 either in forwardor reverse as controlled by the surgeon or surgeon assistant attainsangular displacement of the laparoscope 12 as measured perpendicularfrom the abdominal wall. A total of about 210 degrees of rotation of theC-shaped arm about the Y axis is possible using the Y-axis motor 135.The actual amount of rotation will be limited by the position of theapparatus 10 to the body of the patient. Typically, the total achievedrotational motion with the patient present can be about 180 degrees.Without the patient and motor 130, the total rotation could be 360degrees.

[0084] A remote actuating control unit 150 for the movement of theC-shaped arm 40 and the laparoscope 12 is comprised of common single ordouble pole momentary electrical switches 152-156 typical to thoseskilled in the field. Wiring of the switches 152-156 is typical ofelectric circuitry used to control DC motor on/off momentary functions.Forward and reverse motor control is accomplished by reversingelectrical polarity through the momentary switches 152, 153,respectively, in the control unit 150 as is known. FIGS. 1A and 1B alsoillustrate the left and right rotational switches 154, 155,respectively, and the longitudinal Z-axis endoscope movement switch 156.

[0085] In addition to the control unit 150, the movement of the C-shapedarm 40 and laparoscope 12 can also be controlled using a remote actuatorin the form of a foot activated controller 170 illustrated in FIG. 10.In one embodiment, the foot activated controller 170 includes at leastone foot pedal. In a preferred embodiment, the foot activated controller170 includes a plurality of foot pedals 171, 172 as described in U.S.Pat. No. 5,907,664 to Wang et al., which is fully incorporated herein byreference. In one embodiment, the foot activated controller includes thefirst and second foot pedals as disclosed in U.S. Pat. No. 5,907,664. Inthis embodiment, the foot pedal 172 has a plurality of spaced pressuretransducers or switches 173 that can be simultaneously activated toachieve movement of the C-shaped arm 40 and the laparoscope 12 inmultiple directions at the same time (complex motion). For example, thefirst foot pedal can be used to control the translational movement ofthe laparoscope 12 into and out of the body. The second pedal 172 can beused to control the separate or simultaneous rotational motion of thetrocar adapter 70 and the C-shaped arm 40.

[0086] Alternatively, in another embodiment, the foot activatedcontroller includes three toggled pedals. Each toggled pedal is able tocontact one of two associated motion direction switches. When a pedal istoggled in a given direction (forward or backward; left or right) anassociated switch is closed and the C-shaped arm 40 and the laparoscope12 move in a predetermined path of motion that is assigned to the closedswitch. In this embodiment, one of these toggled pedals controls thedirection of the rotational movement of the trocar adapter 70. Thesecond of the pedals controls the rotation of the C-shaped arm 40, whilethe third pedal controls the translational movement of the laparoscope12 into and out of the body.

[0087] In any of the above embodiments, the foot activated controller170 is wired in parallel with the control unit 150 so that the surgeonor operator of the C-shaped arm 40 has the option of controlling themovement of the C-shaped arm 40 and the laparoscope 12 with thehand-activated control unit 150 or the foot-activated control unit 170.Alternatively, the control unit 150 and the foot activated controllercan be separately wired.

[0088] In yet another embodiment, a control unit for the positioning ofthe C-shaped arm 40 and the laparoscope 12 could include voicerecognition software and a computer having a processor that causes oneor more motion control switches to be activated when the softwareidentifies a directional command given by an attendant or the surgeon.The motion control switches will cause the C-shaped arm 40 and thelaparoscope 12 to move according to the voice commands.

[0089] Electric cables and connectors used to carry voltage and amperagefor motor control unit 150 are typical of components used in the lowvoltage direct current electric industry. Of course wireless remotecontrol technology can also be used to control the “X”, “Y” and “Z” axisdrive motors. The wireless control could be similar to the key ringcontrol for automobile alarm systems, which typically control solenoidsthat unlock and lock your car doors and open the trunk. Such a systemutilizes switches in the remote control unit that reverse polarity in asolenoid to actuate the lock mechanism either open or closed.

[0090] As illustrated, the present invention includes additionalalternative embodiments for moving the medical instrument 12 along the Zaxis. In an alternative embodiment shown in FIG. 18, the trocar 20′ isreleasably secured to an adapter 310 that carries and supports thehousing 61 for the endoscopic instrument drive assembly 60. In thisembodiment, the trocar 20′ is held within a releasable clamp 302 thatincludes a pivotable clamping member 304 with a first end 305 thatpivots relative to the support adapter 310 and a second end 306 that isreleasably held by a locking protrusion 307. In this embodiment, thesupport adapter 310 can be permanently or releasably secured to thefirst end section 42. For example, the support adapter 310 can include apost 312 that extends in the direction of the first end section 42 andthat is releasably connected to a portion of the first end section 42 bya quick release coupling, such as a bayonet mount connector, theconnector illustrated in FIG. 11E or the connector illustrated in FIG.24. As seen in the figures, the support adapter 310 can provide anoffset jog for the trocar 20′ relative to the body of the patient toovercome elevations in the profile of the patient's body. The supportadapter 310 also includes a plate 318 that can support the lower surfaceof the housing 61 or that can form the lower surface of housing 61. Thehousing 61 can include any of the motor and roller arrangementsdisclosed herein for moving either the endoscopic instrument 12 or thetrocar 20′.

[0091] As shown in FIG. 19, the trocar 20′ in this embodiment caninclude a necked region 308 for receiving the clamping member 304.Additionally, the area above the necked region 308 can have anyconfiguration that permits trocar 20′ to mate with the plate 318 and bealigned with the instrument receiving opening 59 within the housing 61and receive the instrument 12 as it moves along the Z axis.

[0092] In the embodiment illustrated in FIG. 20, the first end section42 is connected to a support adapter 410 by any connection discussedherein, for example a quick release coupling such as those discussedherein. The first end section 42 is capable of rotating relative tosection 44 as discussed above. Additionally, like the other supportadapters discussed herein, support adapter 410 can include a heightadjustment mechanism, discussed below, that allows the distance betweenthe body of the patient and a motor drive assembly 460. The supportadapter 410 includes a first elongated shaft 411 that can be releasablycoupled to the first end section 42 and a vertical member 412 connectedto the drive assembly 460 that includes a housing 461 carrying rollersfor driving the endoscopic instrument 12. The drive assembly 460 issimilar to drive assembly 60 except for the points discussed below. Thesupport adapter 410 does not include a connection to the trocar 420.Instead, the trocar 420 is able to move independent of the supportadapter 410 prior to the insertion of the endoscopic instrument 12 intoboth the motor housing 460 and the trocar 420. The trocar 420 is heldwithin the body by the friction between the skin at the surgical openingand the outer surface of the trocar 420. This friction is greater thanthe friction between the trocar 420 and the received endoscopicinstrument 12. As understood, when the endoscopic instrument 12 ispositioned within the trocar 420, the trocar 420 will rotate with therotation of the endoscopic instrument in response to the motion of thesupport adapter 410 and the first end section 42.

[0093] The drive assembly 460 includes an opening 459 for receiving theendosopic instrument 12 and through which the endoscopic instrument 12moves as it is advanced or retracted along the Z axis. As shown in FIGS.20 and 21, the drive assembly 460 includes a pair of drive motors 462and a pair of associated drive rollers 464 that are connected to theoutput shafts 465 of the motors 462. A friction material, as discussedabove with respect to roller 63, 64, for engaging and driving theendoscopic instrument 12 along the Z-axis, covers each roller 464. Themotors 462 and rollers 464 can be moveable within the housing 461, forexample on moveable chassis, and lockable in multiple positions in orderto adjust the space between the rollers 464. As a result, endoscopicinstruments 12 of different sizes (diameters) can be accommodatedbetween the rollers 464 and driven without slippage. In an alternativeembodiment, the drive assembly 460 can contain a single driven roller464 and an idler roller as discussed above.

[0094] An embodiment of a quick release coupling between two parts of anadapter 410′ is illustrated in FIGS. 38A-38J. In this embodiment, aportion 413′ of the adapter 410′ is connected to the first end section42. This portion 413′ includes a plurality of flat surfaces 411′, arecessed groove 412′ and movement limiting plates 414′. The end of acooperating vertical support member 417′ includes a jaw 415′ thatcooperates with, and clamps around, the portion 413′ of the adapter 410′between the movement limiting plates 414′. A sliding member 415′ movesat the end of the adapter 410′ from a first, open position at which thejaw is open to receive the portion 413 to a second, closed positionwhere the sliding member 415′ moves along the groove 412′ and beneaththe portion 413′ to hold the vertical portion 417′ of the adapter 410′on the first end section 42. As illustrated, the adapter 410′ includes aplurality of through holes 420′ that are spaced from each other alongthe length of the member 417′. In this embodiment, a drive assembly 820′has a housing 821′ that includes a spring loaded pin, rod or threadedmember 830′ that can be removably positioned within one of the throughholes 420′ corresponding to a desired height of the trocar 20 relativeto the body of the patient. The drive assembly 820′, such as any ofthose disclosed herein, can include an opening 822′ in its housing 821′for receiving the adapter 410′ so that the drive assembly 820′ canadjustably move along the length of the adapter 410′.

[0095] In the embodiment illustrated in FIGS. 38A-38J, the driveassembly 820′ is substantially identical to motor drive assembly 820illustrated in FIGS. 34-37. Like elements of these embodiments areidentified using the same reference numerals. In addition to opening822′, the drive assembly 820′ also includes a cage 851′ that maintainsthe rollers 834, 835 in alignment with each other. In a firstembodiment, these rollers 834, 835 are aligned in parallel with eachother. Also, the pivotable first housing section 842′ includes a lever843′ that is pivotably secured to the cage 851′ about a point 845′ forholding the pinch roller 834 in position and moving the pinch roller 834relative to the drive roller 835.

[0096] The adapter 410′ can be secured to the trocar 20′ as shown inFIG. 19 or it can be snap fit or otherwise secured to the housing 821′in accordance with any of the discussed embodiments. FIGS. 38A and 38Ealso illustrate middle section 44 including a spring loaded pin, rod orthreaded member 900 and holes 902 that allows the section 42 to beincrementally and telescopically spaced from the end of the middlesection 44.

[0097] In another alternative embodiment as illustrated in FIG. 23, thedrive assembly 460 can include an odd number of rollers 464 (one drivenand two idler/two driven and one idler) with a majority of the rollerson one side of the introduced endoscopic instrument 12 in order toorient the endoscopic instrument 12 and maintain its plane relative tothe body of the patient. Other motor and roller arrangements discussedherein could also be used within housing 461. For example, the motorscould be positioned within the rollers as discussed below.

[0098] In another embodiment for moving the endoscopic instrument alongthe Z axis illustrated in FIGS. 24-30, the present invention includes atrocar 600 with a drive assembly 620 including a drive motor assemblyhousing 621 that contains at least one drive roller for engaging andmoving an inserted endoscopic instrument 12. The trocar 600 can beconnected to the first end section 42 by any of the connections,including the quick release couplings discussed herein. For example, asshown in FIG. 24, the trocar 600, in addition to its conventionalinsulfation valves, can comprise a quick release coupling 603 includinga keyed or splined adapter shaft 602 that releasably engages acomplimentary receptacle 606 on the end of the first end section 42.Detents 607 can be included in the receptacle 606 for securely holdingthe shaft 602.

[0099] As shown in FIGS. 25-27, the trocar 600 also includes a firsttrocar seal 610 with a seal wiper 611 at an upper opening 659 throughwhich the endoscopic instrument 12 is inserted and a second trocar seal612, such as a duck bill or flapper valve, at the position where theendoscopic instrument 12 exits the motor housing 621 or just below thisposition.

[0100] The drive assembly 620 can include any combination of motors,drive roller and/or idler rollers. For example, in a preferredembodiment illustrated in FIGS. 24-26, the drive assembly 620 includes apair of thin profile (pancake) motors 624(a) and 624(b) that each rotatetwo rollers 625 in opposite directions for advancing and withdrawing theendoesopic instrument 12 from within the trocar 600.

[0101] In an alternative embodiment illustrated in FIGS. 27-30, thedrive assembly 620 can include a motor, at least a pinch roller (notshown) and a driven roller 635 or a pair of cooperating driven rollers635. In a preferred embodiment, the motors 636 for the driven rollers635 can be positioned within a centrally located opening in the rollers635 to reduce the size of the motor housing 621. In this embodiment, theeach motor 636 extends in a direction opposite that of the other motor636 within the housing 621. Additionally, each motor 636 includes adrive wheel at one end that engages a support ring 638 on which theassociated roller 635 is mounted. The other end of each motor 637 ispositioned within a bearing 639 in the housing 620. As a result, whenthe motors 636 operate, the drive wheels (not shown) engage the supportrings 638 secured to the rollers 635 and drive the rollers 635 in theirintended direction in order to effect the desired movement(introduction/retraction) of the instrument 12 within the body of thepatient. The drive rollers 635 can be formed of a rubber as discussedabove and they can be moveable along with their motors 636 within thehousing 621 to accommodate instruments 12 having different diameters.

[0102] FIGS. 31-33 illustrate an alternative embodiment of the trocar600. FIGS. 31-33 illustrate a trocar 700 through which an endoscopicinstrument 12 can be advanced into, and retracted from, the body of apatient. Like the above-discussed embodiments, the trocar 700 comprisesan elongated tubular member 702 having a first, percutaneous oratraumatic tip end 706 and a second, opposite end 708 with to amotor/drive assembly 720 that can be connected to the C-shaped arm 40.The motor/drive assembly 720 includes a housing 721, a driven roller 735and a pinch (idler) roller 734 that is biased toward the driven roller735 for contacting the inserted endoscopic instrument 12 in order toadvance and retract the endoscopic instrument 12 within the trocar 700.The trocar 700 also includes a motor enclosure 736 that covers aconventional rotary drive motor. In one exemplary embodiment, the drivemotor within the enclosure 736 includes a MD 1622 gear motor mated witha MD 15P gear head, both of which are available from Micro-Drives ofClearwater, Fla.

[0103] As understood, the drive motor includes an output shaft 738connected to the driven roller 735 for transferring the rotationalmovement of the output shaft 738 to the driven roller 735. As a result,the driven roller 735 will rotate in response to the rotation of theoutput shaft 738 and in the direction dictated by the rotationaldirection of the output shaft 738. Therefore, when the output shaft 738rotates in a first direction, the driven roller 735 will rotate in adirection that advances the endoscopic instrument 12 into the body ofthe patient. Conversely, when the output shaft 738 rotates in a second,opposite direction, the driven roller 735 will rotate to retract theendoscopic instrument 12 from within the body of the patient.

[0104] As illustrated in FIGS. 32 and 33, the pinch roller 734 is biasedtoward the driven roller 735 by a biasing mechanism 740. In a firstembodiment illustrated in FIG. 32, the biasing mechanism 740 includes apivotable arm 742 having a first end 744 securely connected to the pinchroller 734 and a second, opposite end 746 securely connected to a pivotpoint 748 located within the housing 721 so that the pivotable arm 742and pinch roller 734 can rotate relative to the driven roller 735 aboutthe pivot point 748. Elongated member 752, such as rigid pins, extendsfrom the support shafts for both the pinch roller 734 and the drivenroller 735. A spring 754 is attached to each elongated member 752 andextends between these elongated members 752 as shown in FIGS. 31-33. Thespring assumes an extended state when an endoscopic instrument ispositioned within the trocar 700. The tension force of the spring 754causes relative motion between the pinch roller 734 and the drivenroller 735 so that an endoscopic instrument 12 that extends through thehousing 721 is pinched between the pinch roller 734 and the drivenroller 735. As a result, the rotation of the rollers 734, 735 causes theendoscopic instrument to move within the trocar 700.

[0105] The spring 754 can be changed so that the pinching force appliedto the endoscopic instrument by the rollers 734, 735 can be adjusted.For example, when the pinching force applied by the rollers 734, 735needs to be reduced, a longer spring or a spring with a smaller springcoefficient can be connected to each elongated member 752 and betweenthe rollers 734, 735. In an alternative embodiment, both ends 744, 746of the elongated arm 742 could be linearly moveable relative to thedriven roller 735. In this alternative embodiment, a spring 754 could bepositioned at both ends of the arm 742 and connected to one or morepinch rollers for forcing the roller(s) into engagement with an insertedendoscopic instrument and toward the driven roller 735. This isadvantageous when the motor/drive housing 720 includes a plurality ofpinch rollers 734 and a plurality of driven rollers 735. This is alsoadvantageous when a driven roller 735 is positioned between two spacedpinch rollers 734.

[0106] FIGS. 34-37 illustrate an alternative embodiment of an apparatusfor driving a medical instrument relative to a patient according to thepresent invention. The apparatus includes drive assembly 820 including amotor housing 821. Like the other embodiments discussed above, openings810 in the drive assembly housing 821 are axially aligned with apassageway that extends between a pinch roller 834 and a driven roller835 for receiving an endoscopic tool 12 (see FIG. 35).

[0107] In this alternative embodiment, the housing 821 includes a firsthousing portion 822 with an internal space 823 that receives at least apart of a second housing portion 842 as shown in FIG. 36. The internalspace 823 is sized to receive the second housing portion 842 so that thesecond housing portion 842 can move within and relative to the firsthousing portion 822. As illustrated in FIG. 34, the first housingportion 822 includes a tapered section 825 that exposes a portion 843 ofthe received second housing portion 842 so that an operator cansimultaneously contact the first and second housing portions 822, 842when she grasps the motor housing 821. The first housing portion 822also includes a motor 836, such as that discussed above fromMicro-Drives, and a drive shaft 838 extending from the motor 836. Thedrive roller 835 is secured to drive shaft 838 so that the drive roller835 rotates in response to the movement of the drive shaft 838 in orderto advance or retract the endoscopic instrument 12. The first housingportion 822 further includes a pin 824 that extends parallel to aninserted endoscopic instrument 12 as shown in FIGS. 36 and 37. The pin824 forms a pivot point 826 about which the received second housingportion 842 pivots when the housing 821 is grasped and the secondhousing 842 is forced toward the motor 836.

[0108] A spring 850 extends between and connects the first and secondhousing portions 822 and 842 as illustrated in FIG. 36. The spring 850includes a first end 852 securely positioned within an opening 827 inthe first housing portion 822 and a second end 854 secured within anopening 846 in the second housing portion 842. Both ends 852, 854 of thespring 850 can be connected to their respective housing portions 822,842 in a conventional manner. In a preferred embodiment, the ends 852,854 of the spring 850 are secured around or through a cylindrical postthat extends within a respective one of the openings 827, 846. In analternative embodiment, the ends 852, 854 of the spring 850 are directlysecured to a member within a respective one of the openings 827, 846 bywelding, soldering, adhering or the like.

[0109] The second housing portion 842 includes an elongated shaft 844having a first end 845 secured within an opening 846 and a second end847 carrying the pinch roller 834. The pinch roller 834 is rotatablysecured about the shaft 844 by a bearing as is known. Additionally, likethe other rollers discussed herein, the rollers 834 and 835 include aresilient, friction covering material such as neoprene, rubber, etc. Theroller 834 extends a distance away from a contoured edge 849 of thesecond housing portion 842 that is greater than the distance that theouter covering(s) of the roller 834 will compress so that the roller 834can contact and apply pressure to the endoscopic instrument 12 withoutinterference from the second housing portion 842.

[0110] In operation, the trocar housing 820 is grasped so that thesecond housing portion 842 moves relative to the first housing portionand into the internal space 823 to assume the position shown in FIG. 37.This movement of the second housing portion 842 causes the roller 834 topivot away from the opening 810 and the driven roller 835. As a result,the endoscopic instrument 12 can be easily introduced into the housing821 without having to overcome the friction created by a spring biasedpinch roller 834. After the endoscopic instrument 12 has been positionedwithin the housing 821, the tension of the extended spring 850 causesthe second housing portion 842 to pivot back toward the position shownin FIG. 36. The movement of the pinch roller 834 toward the positionshown in FIG. 36 will be limited by the diameter of the endoscopicinstrument 12. As a result, when the pinch roller pivots toward thedriven roller 835, the pinch roller 834 is forced into engagement withthe endoscopic instrument 12 so that it can cooperate with the drivenroller 835 to move the endoscopic instrument 12 along the length of thetrocar. The strength with which the pinch roller 834 engages theendoscopic instrument 12 can be adjusted by changing the length and/orspring constant of the spring 850. In an alternative embodiment, thedriven roller 835 and the motor 836 can be positioned within the secondhousing portion 842 and the pinch roller 834 can be secured to a memberextending into the first housing portion 822.

[0111] In any of the above-discussed embodiments, the motors or theiroutput drive shafts can each include a well-known torque limiting devicesuch as a well-known slip clutch. Each torque limiting device can bepositioned within one of the motors. Alternatively, the torque limitingdevice can be positioned on an end of an output drive shaft between themotor and a driven gear. The toque limiting devices limit the amount oftorque that can be applied to the body of the patient as the C-shapedarm 40 or any part of the C-shaped arm 40 is rotated relative to thebody. As a result, body damaging torques are prevented from beingapplied to the body. Known slip clutches that can be used with thepresent invention are available from Stock Drive Products/SterlingInstruments.

[0112] While there have been shown and described and pointed outfundamental novel features of the present invention as applied topreferred embodiments thereof, it will be understood that variousomissions and substitutions and changes in the form and details of thedevices illustrated, and in their operation, may be made by thoseskilled in the art without departing from the spirit and scope of theinvention as broadly disclosed herein. For example, chain or belt drivesmay be used in place of the above-described gears.

I claim:
 1. An apparatus for positioning a medical instrument relativeto a patient, said apparatus comprising: a trocar for extending throughan incision in the patient; a drive assembly for moving the medicalinstrument within said trocar along a first axis that extends in adirection substantially parallel to the length of the trocar; and apositioning system comprising: a rotatable adapter for connecting to andsupporting the drive assembly; a first motor system for rotating saidadapter and trocar about a first point positioned outside the body ofthe patient and a second axis that extends substantially perpendicularto said first axis; and a second motor system for rotating said adapter,said trocar and said first motor system about a third axis that extendssubstantially perpendicular to said second axis.
 2. An apparatusaccording to claim 1 wherein the drive assembly comprises a housinghaving an opening for receiving the medical instrument, and at least onedrive motor.
 3. An apparatus according to claim 2 wherein the driveassembly further comprises a plurality of rollers spaced from each otherfor moving the medical instrument within said trocar.
 4. An apparatusaccording to claim 3 wherein said rollers are friction rollers forengaging and moving the medical instrument in a direction that extendsparallel to a longitudinal axis of said trocar, and wherein a first ofsaid friction rollers is powered by the at least one drive motor and asecond of said friction rollers is an idler roller biased in thedirection of said first friction roller.
 5. An apparatus according toclaim 4 wherein said rollers of said drive assembly comprise at leastone roller for rotating the medical instrument about the longitudinalaxis of the trocar.
 6. An apparatus according to claim 1 wherein saidadapter includes an opening through which said trocar is received.
 7. Anapparatus according to claim 6 wherein said adapter includes a clampingmechanism that removably receives the trocar, said clamping mechanismincluding at least two clamping members moveable relative to each other.8. An apparatus according to claim 7 wherein the first clamping memberis pivotally secured relative to the second clamping member.
 9. Anapparatus according to claim 7 wherein said adapter includes a moveablecoupling system that secures said adapter to a shaft extending from saidfirst motor system.
 10. An apparatus according to claim 9 wherein saidmoveable coupling system comprises a shaft including at least onerecess, at least one ball bearing for being received within said atleast one recess and an outer sleeve having at least one recess forreceiving said at least ball bearing, said outer sleeve being moveablerelative to said shaft of said adapter.
 11. An apparatus according toclaim 1 wherein said first motor system includes a motor having a driveshaft carrying a drive gear; said adapter includes a shaft having anidler gear that meshes with said drive gear; and said adapter rotateswhen said drive gear rotates said idler gear.
 12. An apparatus accordingto claim 11 wherein said first motor system is positioned within anelongated member that extends at an angle to the length of said adapter.13. An apparatus according to claim 12 wherein said second motor systemis operatively connected to said elongated member for rotating saidelongated member about said third axis.
 14. An apparatus according toclaim 13 wherein said second motor system includes a motor and a pair ofcooperating gears that rotate said elongated member about said thirdaxis in response to the operation of the motor of the second motorsystem.
 15. An apparatus according to claim 1 further comprising aremote control unit for selectively operating at least one of a motor ofsaid drive assembly, said first motor system and said second motorsystem.
 16. An apparatus according to claim 1 further comprising asubstantially C-shaped arm having a first section comprised of saidadapter, a second section containing said first motor system and a thirdsection operatively connected to said second motor system.
 17. Anapparatus according to claim 1 wherein said trocar is free of aconnection to said adapter.
 18. An apparatus according to claim 17wherein said drive assembly includes a housing containing a plurality ofrollers for engaging and moving the medical instrument, and wherein saidadapter is secured to said drive assembly housing for rotating saiddrive assembly housing in response to the operation of said first motorsystem and/or second motor system.
 19. An apparatus according to claim 3wherein drive assembly includes a housing containing said rollers andwherein said drive assembly housing is releasably secured to saidtrocar.
 20. An apparatus according to claim 1 wherein said trocarincludes a housing, and wherein at least a portion of said driveassembly is positioned within the trocar housing for moving the medicalinstrument within the trocar.
 21. An apparatus according to claim 20wherein said trocar is removably secured to said adapter such that saidtrocar pivots in response to the rotation of the adapter.
 22. Anapparatus according to claim 1 wherein said second motor system rotatessaid adapter, said trocar and said first motor system about a secondpoint outside the body of the patient that is spaced from said firstpoint.
 23. A system for positioning a medical instrument relative to apatient, said system comprising: a drive assembly for moving the medicalinstrument relative to the patient in a direction that extendssubstantially parallel to a first axis, said first axis beingsubstantially parallel to the length of the medical instrument when saidmedical instrument is positioned within said drive assembly; and apositioning system supported for movement relative to the patient andoperatively connected to the drive assembly for rotating the medicalinstrument, said positioning system comprising: (a) a first motor systemlocated at a first section of the positioning system for rotating saiddrive assembly and the medical instrument about a second axis thatextends substantially perpendicular to said first axis and a first pointlocated outside the body of the patient when a portion of the medicalinstrument is positioned within the body of the patient; and (b) asecond motor system located at a second section of said positioningsystem for rotating said drive assembly about a third axis that extendssubstantially perpendicular to said second axis and a second pointlocated outside the body of the patient when a portion of the medicalinstrument is positioned within the body of the patient.
 24. A systemaccording to claim 23 further comprising: a trocar for extending throughan incision in the patient and for receiving the medical instrument, andwherein said drive assembly is free of a connection to said trocar; andwherein said drive assembly further includes a housing having an openingfor receiving the medical instrument, a plurality of instrument engagingmembers and at least one drive motor for driving at least one of saidinstrument engaging members and said medical instrument.
 25. A systemaccording to claim 23 wherein the drive assembly forms a portion of anelongated trocar and said instrument engaging members includecooperating rollers.
 26. A system according to claim 23 wherein thedrive assembly further comprises a plurality of rollers positionedwithin said housing for moving the medical instrument relative to thepatient, said rollers being spaced from each other within said housing.27. A system according to claim 26 wherein said rollers are frictionrollers for engaging and moving the medical instrument in a directionthat extends parallel to a longitudinal axis of said trocar, and whereina first of said friction rollers is powered by the at least one drivemotor and a second of said friction rollers is an idler roller biased inthe direction of said first friction roller.
 28. A system according toclaim 27 wherein said rollers of said drive assembly further comprise atleast one roller for rotating the medical instrument about thelongitudinal axis of the medical instrument and relative to the body ofthe patient.
 29. A system according to claim 24 further comprising anadapter including a moveable coupling system that secures said adapterto a shaft extending from said first motor system.
 30. A systemaccording to claim 29 wherein said coupling system comprises a shaftincluding at least one recess, at least one ball bearing for beingreceived within said at least one recess and an outer sleeve having atleast one recess for receiving said at least one ball bearing, saidouter sleeve being moveable relative to said shaft of said first motorsystem.
 31. A system according to claim 23 further comprising an adapterincluding an elongated member extending from said positioning system,said elongated member including at least one clamping member.
 32. Asystem according to claim 23 further comprising an adapter including ashaft and an idler gear, and wherein said first motor system includes amotor having a drive shaft carrying a drive gear that meshes with saiddrive gear; and said adapter rotates when said drive gear rotates saididler gear.
 33. A system according to claim 32 wherein said first motorsystem is positioned within an elongated portion of said positioningsystem that extends at an angle to a length of said adapter.
 34. Asystem according to claim 33 wherein said second motor system isoperatively connected to said elongated portion of said positioningsystem for rotating said elongated portion of said positioning systemabout said third axis.
 35. A system according to claim 34 wherein saidsecond motor system includes a motor and a pair of cooperating gearsthat rotate said elongated portion of said positioning system about saidsecond axis in response to the operation of the motor of the secondmotor system.
 36. A system according to claim 23 further comprising aremote control unit for selectively operating at least one of a motor ofsaid drive assembly, said first motor system and said second motorsystem.
 37. A system according to claim 23 wherein said positioningsystem comprises a substantially C-shaped arm having a first sectionincluding an adapter, a second section including said first motor systemand a third section operatively connected to said second motor system.38. A system according to claim 25 further comprising an adapterincluding a support member, and wherein said drive assembly housing ismoveable along the length of said support member so that said driveassembly housing can be adjustably spaced from the body of the patient.39. A system according to claim 38 wherein said drive assembly housingincludes an opening for receiving said support member.
 40. An apparatusfor positioning a medical instrument relative to a patient, saidapparatus comprising: a drive assembly for moving the medical instrumentrelative to the patient, said drive assembly comprising a motor formoving the medical instrument in a direction that extends along a firstaxis and substantially parallel to the length of the medical instrument;and a medical instrument positioning system comprising: a plurality ofelongated members operatively connected to and supporting said driveassembly; a first motor system including a motor for rotating themedical instrument in opposite directions about a point positionedoutside the body of the patient when a portion of the medical instrumentis positioned within the body of the patient and a second axis thatextends substantially perpendicular to the first axis; and a secondmotor system including a motor for rotating the medical instrument andsaid plurality of positioning system members about a second axis thatextends substantially perpendicular to the length of said first axis.41. The apparatus according to claim 40 wherein said drive assemblyfurther comprises a motor housing including a first housing portion thatis moveable relative to a second housing portion from a first positionto a second position.
 42. The apparatus according to claim 41 whereinthe first housing portion is connected to the second housing portion bya spring, and wherein said spring returns the first housing portion tosaid first position after the medical instrument has been inserted intothe motor housing.
 43. The apparatus according to claim 42 wherein thefirst housing portion is at least partially received within said secondhousing portion.
 44. The apparatus according to claim 43 wherein themotor housing includes a spring for biasing a pinch roller toward adriven roller.
 45. An apparatus according to claim 40 wherein the driveassembly comprises a plurality of rollers spaced from each other formoving the medical instrument.
 46. An apparatus according to claim 45wherein said rollers are friction rollers for engaging and moving themedical instrument in a direction that extends parallel to alongitudinal axis of said trocar, and wherein a first of said frictionrollers is powered by the at least one drive motor and a second of saidfriction rollers is an idler roller biased in the direction of saidfirst friction roller.
 47. An apparatus according to claim 46 furthercomprising a trocar extending substantially parallel to said first axisand wherein said plurality of elongated members form a substantiallyC-shaped arm, said first of said elongated members includes an adapterthat supports said trocar, said second of said elongated membersincludes said first motor system and a third of said elongated membersis operatively connected to said second motor system.
 48. An apparatusaccording to claim 47 wherein said adapter includes a support member,and wherein said trocar is moveable along the length of said supportmember so that said drive assembly of said trocar can be adjustablyspaced from the body of the patient.
 49. An apparatus according to claim47 wherein said second motor system further includes a pair ofcooperating gears that rotate said trocar about said second axis inresponse to the operation of the motor of the second motor system. 50.An apparatus according to claim 40 further comprising a remote controlunit for selectively operating at least one of said drive assemblymotor, said first motor system and said second motor system.
 51. Anapparatus according to claim 40 wherein the medical instrument includesan endoscope.
 52. An apparatus for positioning a medical instrumentrelative to a patient, said apparatus comprising: a first elongatedmedical instrument moveable relative to the body of the patient; a driveassembly for engaging said first elongated medical instrument and movingsaid first elongated medical instrument toward and away from the body ofthe patient; and a positioning system operatively connected to the driveassembly and said first elongated medical instrument for moving saidfirst elongated medical instrument about a plurality of axes and aplurality of spaced points located outside the body of the patient. 53.An apparatus for positioning a medical instrument according to claim 52further comprising a second elongated medical instrument, said secondelongated medical instrument including a trocar having an internalpassageway for receiving said first elongated medical instrument.
 54. Anapparatus for positioning a medical instrument 53 wherein said trocarincludes said motor system, and wherein said motor system includes amotor and a plurality of rollers for engaging said first elongatedmedical instrument and moving said first elongated medical instrumentwithin said trocar.
 55. An apparatus for positioning a medicalinstrument according to claim 54 wherein said trocar is securelyconnected to said positioning system such that said trocar moves inresponse to the movement of said positioning system.
 56. An apparatusfor positioning a medical instrument according to claim 53 wherein saidtrocar is free of a connection to said positioning system.
 57. Anapparatus for positioning a medical instrument according to claim 53further comprising an adapter, and wherein said trocar is secured tosaid positioning system by said adapter.
 58. An apparatus forpositioning a medical instrument according to claim 57 wherein saidadapter supports said trocar relative to the body of the patient.
 59. Anapparatus for positioning a medical instrument according to claim 58wherein said adapter includes a trocar receiving portion having anopening through which said trocar extends.
 60. An apparatus forpositioning a medical instrument according to claim 58 wherein saidadapter includes a first member secured to a housing of said motorsystem and a second member that extends substantially parallel to thelongitudinal axis of said trocar, said first member being moveable alongthe length of said second member.
 61. An apparatus for positioning amedical instrument according to claim 60 wherein said first member hasan internal opening through which said second member extends, andwherein said first member includes a locking member for securing saidfirst member to said second member.
 62. An apparatus for positioning amedical instrument according to claim 61 wherein said first memberincludes a moveable elongated member and said second member includes aplurality of holes spaced at intervals for receiving said moveableelongated member, and wherein said first motor system includes a drivemotor, a first roller driven by said drive motor and a biased followerroller.
 63. An apparatus for positioning a medical instrument accordingto claim 62 wherein the motor system housing includes a moveableportion, and wherein said biased follower roller is positioned withinsaid moveable portion such that said follower roller moves relative tosaid driven roller when said moveable portion travels relative to saidfirst member of said adapter.
 64. An apparatus for positioning a medicalinstrument relative to a patient, said apparatus comprising: a verticalsupport member; a first motor system supported by said vertical supportmember, said first motor system including a motor and a drive system; afirst link having a first end pivotally secured to said vertical supportmember, wherein said drive assembly is operatively coupled to said firstend of said first link for driving said first link about a pivot point;an arm having a first portion secured at a fixed angle to a portion ofsaid first link, said portion of said first link being spaced from saidfirst end of said first link, said arm including a second motor system;an adapter having a first end secured at a fixed angle to a secondportion of said arm, said adapter being operatively connected to saidsecond motor system for rotating said adapter relative to said arm, andwherein said adapter is capable of supporting the medical instrument.65. The apparatus of claim 64 wherein said adapter includes a driveassembly for moving the medical instrument relative to the body' of apatient.
 66. The apparatus of claim 65 wherein said arm islongitudinally moveable relative to said first link.